Retirement

What Does Medicare Not Cover? Five Things To Look Out For

Medicare is a lifesaver for most retirees who need affordable health coverage after age 65. However, it’s very different from the health insurance plan you may have participated in as an employee benefit. For example, Medicare doesn’t provide coverage for some essential items that are often delivered through employer-sponsored health plans.

If you’re nearing age 65 and planning to sign up for Medicare, it’s essential that you find out if Medicare covers the specific services you need to maintain your health and enjoyment of life. Once you know what may be missing, you can make alternative arrangements.

Let’s take a deeper look at Medicare to find out more, starting with the services it does cover.

What Does Medicare Cover?

The services you receive through Medicare will depend on whether you participate in Original Medicare or a Medicare Advantage plan. Following is a summary of the various parts of Medicare that will help explain the differences.

Original Medicare coverage includes Medicare Part A (hospital insurance) and Medicare Part B (medical insurance):

  • Part A covers inpatient services that are typically delivered at a hospital, including room and board, surgery, in-hospital care, lab tests conducted by the hospital, in-patient mental-health services, skilled nursing facilities, hospice care and some home-health care. If you paid FICA taxes for at least 10 years, you won’t have to pay a premium for Part A. The coverage you get under Part A comes with significant deductibles and copayments.
  • Part B covers outpatient medical services, including visits to and treatments by doctors and other health care providers, outpatient diagnostic lab tests and research, durable medical equipment, ambulance services, outpatient mental-health services, and some home-health care. Part B coverage requires participants to pay a monthly premium that, in 2024, is at least $174.70; affluent retirees may also have to pay a surcharge. The coverage you get under Part B comes with significant deductibles and copayments.

Medicare Advantage (MA), also known as Medicare Part C, is a Medicare-approved plan from a private company that offers an alternative to Original Medicare for your health coverage:

  • Medicare Advantage (MA) plans provide services through a managed care environment. MA plans typically combine Parts A and B, and many MA plans also cover the cost of prescription drugs under Part D. They may also deliver limited services not covered by Original Medicare, such as some dental, hearing and vision services. MA plans have their own set of deductibles and copayments. They typically require a monthly premium that’s at least equal to the Part B premium and often require an additional premium to cover the cost of Medicare’s deductibles and copayments.

Medicare also offers prescription drug coverage:

  • Part D of Medicare provides prescription drug coverage and has its own set of premiums, deductibles and copayments. As noted above, some MA plans offer Part D coverage for prescription drugs. If you participate in Original Medicare, however, you’ll need to purchase Part D coverage to be reimbursed for the cost of prescription drugs.

By contrast, most employer-sponsored health plans aren’t nearly as complex as Medicare. They typically have one set of premiums, deductibles and copayments for the various services described previously. They may also cover some services that Medicare doesn’t cover, described next. In addition, there are many more features of Medicare you may want to learn about prior to signing up for Medicare coverage.

Many retirees in Original Medicare buy Medicare Supplement plans, aka Medigap plans, that will pay for Medicare’s deductibles and copayments under Parts A and B. Retirees participating in an MA plan should not buy a Medicare Supplement Plan, since an MA plan would have its own set of deductibles and copayments.

Now let’s look at five categories of services that Medicare doesn’t cover.

1. Medicare Doesn’t Cover Most Dental Services

Medicare doesn’t cover most dental services, like routine cleanings, fillings, tooth extractions, or dentures. It may cover certain services that could help with other medical conditions.

Retirees can buy stand-alone dental insurance. Another option is to inform your dentist that you’re on Medicare and ask the dentist to charge you the discounted rates they might charge people covered under employer-sponsored dental plans.

2. Medicare Doesn’t Cover Hearing Services

Medicare doesn’t cover the cost of hearing exams or hearing aids. As a result, be sure to shop around to learn about the many recent innovations that have significantly reduced the cost of hearing aids.

3. Medicare Doesn’t Cover Most Vision Services

Medicare doesn’t pay for eye exams, eyeglasses or contact lens. It may cover exams and treatments for certain diseases of the eye, such as glaucoma and macular degeneration.

4. Medicare Doesn’t Cover Long-Term Care Services

Medicare doesn’t cover the cost of services that help frail people with the daily activities of living, such as bathing, using the bathroom, getting dressed, preparing food and taking medications. Retirees can buy long-term care insurance to help pay for these services.

5. Miscellaneous Services That Medicare Doesn’t Cover

Here’s a partial list of other medical services that Medicare doesn’t cover:

  • Cosmetic surgery
  • Massage services
  • Routine foot care
  • Some chiropractic or acupuncture services that aren’t deemed to be medically necessary or don’t address low-back pain
  • Most medical services delivered outside the United States
  • Many forms of alternative or experimental medicine
  • Most over-the-counter drugs

By now, your head may be spinning, but hang in there! Learning about the services that Medicare does and doesn’t cover is an important part of your retirement planning — these services can help you stay alive and healthy. Also, shopping carefully for Medicare Advantage plans or Part D prescription drug plans can help you save money. Do your homework so you choose wisely.

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